Interviews of International Experts on Universal Health Coverage

Dr. Dianne Mcintyre (University of Cape Town, South Africa)

Dr. McIntyre is the South African Research Chair in ‘Health and Wealth’ and a Professor in the School of Public Health and Family Medicine at the University of Cape Town, where she has worked since 1988. She founded the Health Economics Unit (HEU) in 1990 and was its Director for 13 years. She has completed Bachelor of Commerce, Honours and MA in Economics at the University of Cape Town.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr. McIntyre: The core of the universal system for the report is public funding, particularly tax funding, because that is the most equitable and efficient way of actually achieving universal coverage. Given that we in South Africa are also working towards Universal Health Coverage, I completely support the recommendation to have a general pool of money funding the scheme instead of raising it from the public. This will not generate a great deal of revenue and will harm further by alienating a certain section of the society too poor to contribute.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Dr. McIntyre: Not at all. The report does not just focus on increase in expenditure but it does actually presents some ways, in which, it can be translated into improved access for people on the ground. It is not simply creating an entitlement, particularly in terms of the proposals around primary healthcare and improving primary healthcare but actually improving geographic access and other forms of physical access like availability of medicines as well as financial protection.

Q: What is your stand on user fees?

Dr. McIntyre: The international evidence is clear that out-of-pocket payments are not the equitable or the efficient way of paying for health services. Very often, user fees or payments in a universal system are seen as a mechanism for reducing moral hazards or excessive use of healthcare services. But actually the international literature does not demonstrate at all that out-of-pocket payments are effective in reducing moral hazards. If one is concerned that there might be excessive use of health services, there are other mechanisms particularly on the supply side that can be put in place to try to avoid that. Essentially, the key point is: - one, that the international agreements that out-of-pocket payments are not the way to go about funding public health services. Secondly, there is no proof that they achieve the objective of avoiding any moral hazards.

Q: What is the feasibility in contracting private players for public purposes?

Dr. McIntyre: I think it is feasible. This is something we are talking about in South Africa as well. It is got to be in context of a very strong public sector because if the private sector is the stronger component, it will be very difficult as they would be a very powerful lobby. There are also concerns about putting in a whole lot of money together which then suddenly goes into private providers if there is a profit motive involved. So, there has to be a very strong purchasing capacity and a change in provider payment mechanisms, which the report does recommend. If one is going to purchase from the private providers then you should not ask for a fee for service. So, you can purchase from the private sector but you need a good purchasing capacity and have to change the private provider payment mechanism system. Also, your payment mode should be the same, whether it is a private or public provider.

Q: Will this report regulate private players?

Dr. McIntyre: Absolutely. Regulations when written as guidelines etc are actually difficult to enforce. Whereas, if you hold the purse strings and if you have a large pool of public money that can be used to practice, you can much more effectively enforce change in the behaviour of private providers and public providers for that matter.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr. McIntyre: Coming from South Africa, we are going to through a very similar process at the moment. A lot of the recommendations in the Indian report are almost identical. India and South Africa are not necessarily the norm because, in Africa, we keep talking about pursuing universal health coverage and there is a lot more focus on community based payment schemes or contributory schemes. So, we are not necessarily the norm but I would say that it is very encouraging that some countries are going in this direction.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr. McIntyre: Firstly, there was a very short period to making this report, just a year. So, this is a phenomenal amount of work that has been done. The second thing is that it is always quite difficult to have the vision as well as the detailed plans. This report is a great vision to start working on. There is a bit of a gap in terms of detailing currently but I understand that those are incredibly detailed, technical things.

More detailing is required, particularly around purchasing, provider payment mechanisms and phasing. As the report is incredibly ambitious, especially on the human resource section, how it will be developed will be critical. Meanwhile, one has to think as to what one can be done in the interim to actually start making improvements to put in place so that the other mechanisms start working. But I think all those sorts of things one could not have expected with all the details in this one year in the making of the report. The report definitely needs to evolve and be refined.

Mr. Billy Stewart DFID

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Mr. Stewart: Obviously, the recommendation for increasing expenditure on public health is critical to improve overall levels of health coverage and availability of services. Within that there is some very important recommendation about how that additional expenditure will be used, particularly to focus on the primary healthcare level. I think, the recommendation around the earmarking expenditure for primary care is important to show that additional expenditure will be used for what we know will have the biggest impact on the health of the population.

Q: Does an increase expenditure on health automatically guarantee improvement in health indicators?

Mr. Stewart: Not by itself. It is necessary but not sufficient. India could do a lot more with its current expenditure for health. It not at all well used. A lot of expenditure, especially when you factor it with private and public expenditure, is used for services which will not have a big impact on health. Public expenditure and its' utilization has been improving since the launch of the National Rural Health Mission, but there is a lot more that could be done. In many states apparently, they cannot use the money that is available currently. Just putting new money at the top of a system which is not using all of its money right now is obviously not going to change things overnight. That is where the rest of the recommendation of the report comes from.

Q: What is your stand on user fees?

Mr. Stewart: The evidence internationally is fairly clear that user fees, even if in small amounts, can act as a major deterrent for services. I am particularly interested in where the poorest people are able to access care and they are already subject to not just formal user fees for some things but also for lots of informal things as well. So, to really open up access to the poor people, it will require the space for the formal user fees to be not levied and the space for the informal user fees also becomes less as well. Not having user fees will not be misused for health services. A lot of work is done around the accountability of the system. I think accountability at the end of the day will work best if a patient knows what exactly they are able to get and where and when; an individual patient is face to face with an individual provider knowing best that this will bring a positive effect. If all this is clearly communicated to the people then they will be able to clearly demand what they need. If the Universal Health Coverage Mission is going to be implemented and communicated well to the people, I think it will change the kind of healthcare they are able to get.

Q: What is the feasibility in contracting private players for public purposes?

Mr. Stewart: I think it is feasible. Not that it is not already there as there are many states where they are contracting private providers. Some of the states are successful and some of them are less successful on how to set up those contracts and monitor them. There is a lot of contracting of ancillary services and clinical services that is being done. The capacity of the public sector to be able to contract will be important and how they monitor those services. That is where some of the current ones fall down. I think it may even be beneficial in some respect by subjecting the public sector to a little bit more competition.

Q: Will this report regulate private players?

Mr. Stewart: There is a need to regulate private players, not in a heavy handed way but a need to monitor them on what services they are able to provide, the quality of the services and what drugs are being provided. I think monitoring is needed in the public sector as well.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Mr. Stewart: At some point, many of the developed countries and the middle income countries have realized the vision of themselves as a major power and what they are providing in terms of healthcare is disconnected. India is also recognizing that moment. The more India does something about it, the more it recognizes that most of its health indicators are lacking behind compared to other countries. The report on India will enable it to close the gap with other countries or similar international states and also to overtake other countries fast. What we have seen is that some of the other South Asian countries have actually been faster in correcting their health indicators than India. Overall this is an incredible report for India. A lot of the devil will be in the details on how it will be implemented at the state level, especially at the grassroots level.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Mr. Stewart: Not missing but elements that need to be emphasized more or drawn attention to. I think, there needs to be somewhere more clearly set out, a more credible story on how the quality of the public sector facilities will be improved. The report describes packages of care, HR, information systems, so basically bringing back to say that we will be improving the quality of public health services. The second is that communicating the health services to people that this is what your health services are now and this is what they are going to be or will be available in the given timeline of the implementation process is very important.

Dr. Winnie Yip Health Economics Research Centre, University of Oxford

Dr. Yip is a Professor of Health Policy and Economics at the University of Oxford and Adjunct Associate Professor of Global Health Policy and Economics at Harvard University. She received her PhD in Economics from the Massachusetts Institute of Technology, USA. Her primary research interests include incentives and provider behavior; health care system design and impact evaluation of health system interventions; delivery of cost-effective health interventions; and social, economic and cultural determinants of health and well-being.

Q: What in your opinion is the most notable recommendation made by the High Level Expert Group (HLEG) in the report on Universal Health Coverage for India?

Dr Yip: The highlight of the report, according to me, is the concept of funding this scheme by generating tax based revenues. Having said that, the idea of doing away with user fee, increasing access to medicines, scaling up infrastructure and investing in human resources are all critical aspects if India is serious about achieving Universal Health Coverage by 2022. The key will be in implementation and more specifically, implementing a scheme without it pinching the pockets of economically weaker sections of the society will be critical in determining how successful India is.

Q: What is your stand on user fees?

Dr Yip: From the point of view of protecting people’s financial risk and also assuring access to care, I don’t think people should be subject to high out of pocket payment. However, I think user fees are tied fundamentally to whether the government is increasing funding directly to the supply side, or whether it’s going to channel it through a third party purchaser. If it chooses to channel them through a third party purchaser, then, by definition, it will charge a user fee. However, you can then use the third party purchaser to reimburse people, and people end up paying very little. Therefore, I think the issue of user fees is tied with the fact that there’s an assumption that the money should be given directly to the supply side, and if that’s the definition, then yes, I think there’s a strong argument for no user fees.

Q: What is the feasibility in contracting private players for public purposes?

Dr Yip: I would say international experience so far suggests that it’s very complicated and difficult, and poses a few questions. What do you contract on? Which is the agency that has the capacity and technical understanding to choose good quality providers? What is not clear in this report is whether the government is going to select public and private providers on equal footing. Does the government assume that the public provider would definitely get a budget? In that case, the private provider would only come in and fill the gaps as necessary.

Are you then able to use competitive forces to contract and bring in the best provider? Another question is: Who’s the purchaser? What is the incentive for the purchaser to buy on behalf of the patients, and to improve healthcare quality and health outcomes?

Q: Will this report regulate private players?

Dr Yip: Aside from regulating the private sector, the report has a very heavy element of introducing regulation and management for even the public sector. My experience of China is that you can issue a lot of regulation. However, the critical point is the enforcing of these regulations. If you can’t enforce them, then they become irrelevant. I think that management has a role to play in improving quality. However, my experiences with China and other countries shows that you need some stimulation for that management to work. Unless you subject the provider to provider payment charge or market competition, there’s very little incentive for them to introduce improved management.

Q: How does the HLEG report made for India compare with several other versions of Universal Health Coverage currently in place in several other countries?

Dr Yip: I’m most familiar with China, and I can draw some parallels there. There are lots of similarities. China had this reform plan issue in 2009, and it said it wants to achieve universal health coverage by 2020. This report wants to achieve the same by 2022. The way China are going about it is by significantly increasing government tax revenue. They are targeting primary healthcare, building equipment, infrastructure, and training the primary healthcare workforce. Thus, there are lots of similarities. Aspects such as developing an essential medicine programme of competitive bidding, selecting and developing a national essential drug list, are similar elements, with the major difference being that India chooses to have the increased funding channeled to public providers directly, with some contracting of private players. However, China has decided to channel it through a third party. I think china did this mainly because it has no confidence that by giving the budget directly to the public provider, it can stimulate any quality or efficiency improvement.

Q: Do you think there are any missing elements that need to be introduced in the report to make it more robust?

Dr Yip: I think the report is missing the entire incentive structure completely. What is the problem with the current incentive structure? Why are public providers not showing up for work? Why are providers providing poor quality service? Why do they go up and have a private clinic on the side? Would they still continue doing it? Without addressing all these incentive problems, the old problems will still exist.